Rheumatoid Arthritis (RA) is a chronic inflammatory disorder, which characteristically has joint involvement. The prevalence is about 0.8% (approximately 2.9 million people in Europe) with some variation among ethnic groups. RA is more common in women than men.
In the RA disease process, inflammation involves the synovium and may cause damage to the cartilage and bone itself. Areas that may be affected include the joints of the hands, wrists, neck, jaw, elbows, feet, and ankles. Often RA causes the joints of the body to be affected in a symmetrical manner, meaning that the disease attacks the same joint on both sides of the body—for example, both hands.
Diagnosis of RA is currently made according to the criteria set out by the American College of Rheumatology in 1987 (published in Arnett et al., Arthritis and Rheumatism March 1988; 31(3):315-24).
A number of pharmacological agents are commonly used to manage the signs and symptoms of RA. These fall into four main classes: NSAIDs (nonsteroidal anti-inflammatory drugs) that relieve the pain and inflammation associated with RA; DMARDs (disease-modifying antirheumatic drugs) that both relieve symptoms and help to control RA by modifying its disease process); Glucocorticoids (a group of anti-inflammatory drugs that are related to cortisol, a natural steroid hormone produced by the body); and Biologicals (drugs like Kineret® (anakinra) that are designed to target specific molecules in the immune system that contribute to the RA disease process.
Epidemiologic and genetic studies have provided evidence of the presence of genetic susceptibility factors for RA, accounting for approximately 60% of the variation in liability to disease. Identification of those genes related to RA could bring a better understanding of the pathogenesis, diagnosis, location, and prognosis and eventually appropriate adequate treatment. From a clinical point of view, early diagnosis, prognosis and location of the disease would signify an important change in therapeutic decisions used for treatment.
Association studies have recently identified several genes in which one or more genetic variations result in a higher or lower risk of contracting this disease, a better or worse response to drugs and/or, a better or worse prognosis. A means of characterising multiple RA associated variations which could be used clinically would provide a great advance in diagnosis and therapy.
DNA-chips are often used to discriminate between alleles at genetic loci.
In 2001, the Consortium for the Human Genome Project and the private company Cetera presented the first complete example of the human genome with 30,000 genes. From this moment on, the possibility of studying the complete genome or large scale (high-throughput) studies began. So-called “DNA-chips”, also named “micro-arrays”, “DNA-arrays” or “DNA bio-chips” are apparatus that functional genomics can use for large scale studies. Functional genomics studies changes in the expression of genes due to environmental factors and to genetic characteristics of an individual. Gene sequences present small interindividual variations at one unique nucleotide called an SNP (“single nucleotide polymorphism”), which in a small percentage are involved in changes in the expression and/or function of genes that cause certain pathologies. The majority of studies which apply DNA-chips study gene expression, although chips are also used in the detection of SNPs.
The first DNA-chip was the “Southern blot” where labelled nucleic acid molecules were used to examine nucleic acid molecules attached to a solid support. The support was typically a nylon membrane.
Two breakthroughs marked the definitive beginning of DNA-chip. The use of a solid non-porous support, such as glass, enabled miniaturisation of arrays thereby allowing a large number of individual probe features to be incorporated onto the surface of the support at a density of >1,000 probes per cm2. The adaptation of semiconductor photolithographic techniques enabled the production of DNA-chips containing more than 400,000 different oligonucleotides in a region of approximately 20 μm2, so-called high density DNA-chips.
In general, a DNA-chip comprises a solid support, which contains hundreds of fragments of sequences of different genes represented in the form of DNA, cDNA or fixed oligonucleotides, attached to the solid surface in fixed positions. The supports are generally glass slides for the microscope, nylon membranes or silicon “chips”. It is important that the nucleotide sequences or probes are attached to the support in fixed positions as the robotized localisation of each probe determines the gene whose expression is being measured. DNA-chips can be classified as:                high density DNA-chips: the oligonucleotides found on the surface of the support, e.g. glass slides, have been synthesized “in situ”, by a method called photolithography.        low density DNA-chips: the oligonucleotides, cDNA or PCR amplification fragments are deposited in the form of nanodrops on the surface of the support, e.g. glass, by means of a robot that prints those DNA sequences on the support. There are very few examples of low density DNA-chips which exist: a DNA-chip to detect 5 mutations in the tyrosinase gene; a DNA-chip to detect mutations in p53 and k-ras; a DNA-chip to detect 12 mutations which cause hypertrophic cardiomypathy; a DNA-chip for genotyping of Escherichia coli strains; or DNA-chips to detect pathogens such as Cryptosporidium parvum or rotavirus.        
For genetic expression studies, probes deposited on the solid surface, e.g. glass, are hybridized to cDNAs synthesized from mRNAs extracted from a given sample. In general the cDNA has been labelled with a fluorophore. The larger the number of cDNA molecules joined to their complementary sequence in the DNA-chip, the greater the intensity of the fluorescent signal detected, typically measured with a laser. This measure is therefore a reflection of the number of mRNA molecules in the analyzed sample and consequently, a reflection of the level of expression of each gene represented in the DNA-chip.
Gene expression DNA-chips typically also contain probes for detection of expression of control genes, often referred to as “house-keeping genes”, which allow experimental results to be standardized and multiple experiments to be compared in a quantitive manner. With the DNA-chip, the levels of expression of hundreds or thousands of genes in one cell can be determined in one single experiment. cDNA of a test sample and that of a control sample can be labelled with two different fluorophores so that the same DNA-chip can be used to study differences in gene expression.
DNA-chips for detection of genetic polymorphisms, changes or mutations (in general, genetic variations) in the DNA sequence, comprise a solid surface, typically glass, on which a high number of genetic sequences are deposited (the probes), complementary to the genetic variations to be studied. Using standard robotic printers to apply probes to the array a high density of individual probe features can be obtained, for example probe densities of 600 features per cm2 or more can be typically achieved. The positioning of probes on an array is precisely controlled by the printing device (robot, inkjet printer, photolithographic mask etc) and probes are aligned in a grid. The organisation of probes on the array facilitates the subsequent identification of specific probe-target interactions. Additionally it is common, but not necessary to divide the array features into smaller sectors, also grid-shaped, that are subsequently referred to as sub-arrays. Sub-arrays typically comprise 32 individual probe features although lower (e.g. 16) or higher (e.g. 64 or more) features can comprise each subarray.
One strategy used to detect genetic variations involves hybridization to sequences which specifically recognize the normal and the mutant allele in a fragment of DNA derived from a test sample. Typically, the fragment has been amplified, e.g. by using the polymerase chain reaction (PCR), and labelled e.g. with a fluorescent molecule. A laser can be used to detect bound labelled fragments on the chip and thus an individual who is homozygous for the normal allele can be specifically distinguished from heterozygous individuals (in the case of autosomal dominant conditions then these individuals are referred to as carriers) or those who are homozygous for the mutant allele.
Another strategy to detect genetic variations comprises carrying out an amplification reaction or extension reaction on the DNA-chip itself.
For differential hybridisation based methods there are a number of methods for analysing hybridization data for genotyping:                Increase in hybridization level: The hybridization level of complementary probes to the normal and mutant alleles are compared.        Decrease in hybridization level: Differences in the sequence between a control sample and a test sample can be identified by a fall in the hybridization level of the totally complementary oligonucleotides with a reference sequence. A complete loss is produced in mutant homozygous individuals while there is only 50% loss in heterozygotes. In DNA-chips for examining all the bases of a sequence of “n” nucleotides (“oligonucleotide”) of length in both strands, a minimum of “2n” oligonucleotides that overlap with the previous oligonucleotide in all the sequence except in the nucleotide are necessary. Typically the size of the oligonucleotides is about 25 nucleotides. The increased number of oligonucleotides used to reconstruct the sequence reduces errors derived from fluctuation of the hybridization level. However, the exact change in sequence cannot be identified with this method; sequencing is later necessary in order to identify the mutation.        
Where amplification or extension is carried out on the DNA-chip itself, three methods are presented by way of example:
In the Minisequencing strategy, a mutation specific primer is fixed on the slide and after an extension reaction with fluorescent dideoxynucleotides, the image of the DNA-chip is captured with a scanner.
In the Primer extension strategy, two oligonucleotides are designed for detection of the wild type and mutant sequences respectively. The extension reaction is subsequently carried out with one fluorescently labelled nucleotide and the remaining nucleotides unlabelled. In either case the starting material can be either an RNA sample or a DNA product amplified by PCR.
In the Tag arrays strategy, an extension reaction is carried out in solution with specific primers, which carry a determined 5′ sequence or “tag”. The use of DNA-chips with oligonucleotides complementary to these sequences or “tags” allows the capture of the resultant products of the extension. Examples of this include the high density DNA-chip “Flex-flex” (Affymetrix).
For genetic diagnosis, simplicity must be taken into account. The need for amplification and purification reactions presents disadvantages for the on-chip extension/amplification methods compared to the differential hybridization based methods.
Typically, DNA-chip analysis is carried out using differential hybridization techniques. However, differential hybridization does not produce as high specificity or sensitivity as methods associated with amplification on glass slides. For this reason the development of mathematical algorithms, which increase specificity and sensitivity of the hybridization methodology, are needed (Cutler D J, Zwick M E, Carrasquillo M N, Yohn C T, Tobi K P, Kashuk C, Mathews D J, Shah N, Eichler E E, Warrington J A, Chakravarti A. Genome Research; 11:1913-1925 (2001).
Thus, despite advances in technology, the problems of existing methods is simultaneously analysing a large number of genetic variations in a sensitive, specific and reproducible way, has prevented the application of DNA-chips for routine use in clinical diagnosis.